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el <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �k0£, 0?lIC1 US3's: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION ,; 0R,'VELL,_CONSTRUCI•ION OR PUMP PERMIT Permit Na. 74/_3SozbJ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �f/,Z(� �r-ce.-���tc� CENSUS TRACT <br /> Owner's Nameyf� - ,� Phone <br /> Address Izz 0 Cit <br /> i <br /> Contractor's Name c? License # Phone ' s` <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN / / RECONDITION /_/ DESTRUCTION 17 <br /> PUMP INSTALLATION 0 PUMP REPAIR / / PUMP REPLACEMENT J� <br /> Other /J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> �r Industrial Cable Tool Dia. of Well Excavation 0 �1 <br /> Domestic/private Drilled Dia. of Well Casing d <br /> Domestic/public Driven Gauge of Casing /12— <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grouter <br /> Other Other Information <br /> L22L22-INSTALLATION: <br /> INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> F <br /> PUMP REPLACEMENT: / / State Work Done _ <br /> PUMP UPAIR: / / State Work Done <br /> ,DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of Califoruia pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of m work. on a neer well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS P f the well and notify them before putting the well in use. The above <br /> informat' ue t my k dge and belief. <br /> SIGNED TITL <br /> & 4�z <br /> (DRAW PLOT PLAN ON REVERSE SI ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> A APPLICATION ACCEPTED BY L ��� fII�� DATE - -7 <br /> ADDITIONAL CO',IMNTS: <br /> PHASE II ROUT INSPECTION PHAS III IN INSPECTION <br /> INSPECTION BY DATE G�r` INSPECTION BY DATE <br /> --CALL -FOR A. GROUT. INSPECTION PRIOR TO GROUTING AND FINAL INSPECTTON.Df� �o� �qll�iz �kd1.I <br /> E H 1426 5/731M <br />